In the Research Letter titled “Association Between Simulation Curriculum and Learners’ Confidence and Interest in Cardiothoracic Surgery,”1 published online July 11, 2018, an author name was misspelled. The name Juston Watson, MD, should have been Justin Watson, MD. The article has been corrected online.

To the Editor Kitz et al1 evaluated the prognostic value of total mesorectal excision (TME) plane in patients with rectal cancer. Total mesorectal excision plane quality was grouped into 3 categories: mesorectal, intramesorectal, and muscularis propria. One end point was disease-free survival (DFS). The authors quantified the between-group differences using 3-year event-free rates and hazard ratios (HRs). Three-year DFS rate estimates for mesorectal, intramesorectal, and muscularis propria TME were 75.9% (95% CI, 73.1-78.8), 68.4% (95% CI, 61.6-76.0), and 67.2% (95% CI, 55.6-81.3), respectively. Because these confidence intervals overlap, it is unclear whether there is a true difference between certain pairs, eg, between intramesorectal and muscularis propria TME. Moreover, in Figure 2A,1 the DFS curves extend up to 60 months. Thus, the 3-year event rate provides a local profile of DFS only. To use data after 3 years, the authors reported HRs for DFS (intramesorectal vs mesorectal TME: HR, 1.35; 95% CI, 1.01-1.80; muscularis propria vs mesorectal TME: HR, 1.73; 95% CI, 1.13-2.66). However, it is difficult to interpret HRs in the clinical context. The hazard is not a chance or probability measure and therefore is not equivalent to risk. Thus, an HR of 1.35 cannot be translated into a 35% risk increase. Also, no reference hazard value from mesorectal TME was provided. If mesorectal TME hazard is low, a 35% increase in hazard may not be clinically significant. Other issues and concerns in using HRs to quantify between-group differences have been discussed extensively.2-4

In this issue of JAMA Surgery, Kwon and colleagues1 studied the use of fluorescent lymphography–guided lymphadenectomy during robotic gastrectomy for gastric cancer. They hypothesized that the peritumoral injection of indocyanine green (ICG) would allow for visualization of every draining lymph node from the primary lesion, therefore allowing a more complete and thorough lymphadenectomy. The day before the scheduled operation, they endoscopically injected 3 mg of ICG in the submucosa around the tumor in 40 patients who had a clinical stage I disease (T1N0M0, T1N1M0, or T2N0M0) according to the 7th staging system of the American Joint Commission on Cancer.2 The gastrectomy was performed using the da Vinci Si Surgical system (Intuitive) equipped with the Firefly mode to acquire near-infrared (NIR) fluorescent images. After propensity score matching, the results in these 40 patients were compared with those of 40 historical control patients who underwent robotic gastrectomy without injection of ICG. The primary outcome was the number of retrieved lymph nodes in total and in each nodal station. The results of their study clearly showed that the use of NIR imaging determined the retrieval of a higher number of harvested lymph nodes per patient, and for stations 2, 6, 7, 8, and 9.

The option to avoid an appendectomy and potential complications of an operation is appealing (especially for patients) in the management of acute, uncomplicated appendicitis (AUA).1-3 A meta-analysis4 demonstrated that 73.4% of patients treated with antibiotics and without appendectomy were cured without major complication, including recurrence of appendicitis and need for operative management. Many questions remain unanswered, including whether a specific patient subpopulation would be better treated one way or another.5 In this issue of JAMA Surgery, the retrospective analysis by Sceats et al6 evaluated the real-world application of nonoperative management of AUA in a cohort of more than 58 000 patients. Interestingly, of the 4.5% of patients who were treated with nonoperative management, only 3.9% required an appendectomy during a mean follow-up of 3.2 years. This rate is substantially less than the 27.3% of patients who eventually required an appendectomy in the largest and most recent randomized clinical trial,1 but similar to those in prior retrospective studies.7 Moreover, the cost of the index hospitalization was lower with nonoperative management. These findings in isolation would support the nonoperative management of AUA. Sceats et al6 also demonstrated that the operative cohort had statistically significant lower numbers of readmissions, office visits, and subsequent complications such as abscess formation. This result led to lower overall costs for patients. These findings would generally support the continued use of routine operative management for AUA.

The opportunity to care for the high-profile or celebrity patient can be a source of recognition and pride for a hospital. That said, caring for this numerically small but reputationally outsized population cannot be allowed to distract from the care of other patients. The high-profile patient can inadvertently disrupt the ability to provide routine care as a result of his or her expectations and demands, the effect of his or her social status on caregivers, or as a result of the measures taken to protect his or her privacy. While there is helpful literature on how to appropriately care for the high-profile patient,1-4 these approaches must be nested in a perspective of ensuring high-quality and reliable care for all patients and protecting their privacy.

To the Editor We thank Fukuda et al1 for their study analyzing the association of prehospital advanced life support (ALS) with the outcomes of out-of-hospital cardiac arrest. The authors conclude that ALS by physicians resulted in a higher 30-day survival than ALS by emergency medical service (EMS) personnel and basic life support (BLS).
However, the implications of the study may be overstated. First, given the retrospective design of the study, there are multiple confounding factors that the authors have not accounted for. These mainly include patient demographic characteristics, like age and sex; modifiable predictors of survival outcomes, like body mass index; general health status as assessed by the American Society of Anesthesiologists index; and comorbidities present, as shown in Table 1.1 Importantly, the extent of blunt injury (assessed by the Injury Severity Score or Abbreviated Injury Scale score) and etiology of cardiac arrest were not evaluated. A major predictor of survival was time to response,2 which was statistically different between the various cohorts (Tables 1 and 3).1 When comparing between EMS and physicians, it is pertinent to match their expertise, since physicians, unlike EMS, may have differing experience and hence success in providing life support.3 Similarly, many patients who survive long enough to reach the hospital for ALS by physicians fare better because of other above-mentioned factors.

In Reply We thank Sterpetti for his response and close attention to our study.1 We agree with the author’s assertion that in the United States, there has been an immense focus on reducing unnecessary blood transfusions, supported by clinical practice guidelines and patient blood management programs.2 The effect of patient blood management initiatives in the United States is evident by recent data showing nationwide decreases in red blood cell (RBC) and plasma transfusions.3

To the Editor I read with much interest the article by Goel et al,1 titled, “Association of Perioperative Red Blood Cell Transfusions With Venous Thromboembolism in a North American Registry.” The authors should be congratulated for their efforts to find causes for postoperative deep vein thrombosis and, eventually, pulmonary embolism. They analyzed data from the American College of Surgeons National Surgical Quality Improvement Program registry regarding 750 937 patients who had surgery in 525 hospitals over a 1-year period. They found that there was a higher incidence of deep vein thrombosis and pulmonary embolism within 30 days from surgery in patients who had received perioperative blood transfusion. About 6.3% of the patients received at least 1 blood transfusion. In a retrospective analysis, they found that blood transfusion was an independent risk factor for thromboembolism and deep vein thrombosis.

Laparoscopic sleeve gastrectomy (LSG) is currently the most frequently performed bariatric procedure worldwide.1 Leak rates between 0% and 5.5% have been reported.2 The long staple line and high intraluminal pressure synergize to create the risk for leaks.3 Leaks are difficult to manage, and 80% of leaks occur after hospital discharge.4 Many surgeons believe that routine gastrografin upper gastrointestinal (GUGI) series on postoperative day 1 or 2 can aid in earlier identification and intervention and can minimize morbidity and mortality in patients who develop a leak.3 This practice is controversial4 and adds to health care cost and radiation exposure, and it should be abandoned.

Intraoperative consultation (IOC) on pathologic specimens, or frozen section in common parlance, is a great boon to the operating surgeon. Immediate information can be made available for the surgical team to guide decision making, such as determining whether to embark on further debridement of a potential necrotizing soft-tissue infection, assessing future clinical consequences, and, most commonly, deciding whether to resect additional tissue. It is in this context that the article by McAuliffe et al1 should be read. The authors present a broad analysis of their institutional experience with gastric and gastroesophageal adenocarcinoma during a 23-year period and including a final cohort of 2002 patients in whom IOC by a pathologist was used. They found an overall diagnostic accuracy for IOC of 98.1%, with a false-negative (FN) rate of 1.7%. They also found that signet ring cell and diffuse-type final diagnoses had higher rates of FN results, ranging as high as 4.7% for those who did not undergo neoadjuvant radiotherapy. These findings are representative of the challenges that face cancer surgeons seeking intraoperative pathologic information.

The study in this issue of JAMA Surgery by Kummerow Broman et al1 is highly relevant to today’s surgeons. The stated aim is to conduct a “pragmatic” investigation into the use of photography in postoperative care, which is commendable, since such care is already widely conducted via smartphone. The most true-to-life scenario would be a surgeon evaluating his or her own patients’ wounds, as firsthand knowledge of the operation and the patient’s underlying risk factors for surgical site infection can be factored into decision making in a way that is lost in hypothetical scenarios (ie, pretest probability can be deployed to improve the positive or negative predictive value of the photographs). Nevertheless, health information technologies are popular with both patients and clinicians,2 and the surgical community needs richer data on both the effectiveness of such tools and their potential pitfalls.
In this study, the pitfalls take center stage. The study was designed to evaluate whether patient-generated photographs improve a surgeon’s ability to remotely determine the likelihood of a wound complication. The answer appears to be no, but even more concerning, the use of photographs seemed to make surgeons more confident in their wrong answers. If a similar false confidence plays out in actual clinical decision making, delays in care may lead to progression of disease.
Thankfully, there is a silver lining in the data. Most surgeons do not use photographs to diagnose surgical site infections; they use photographs as a triage mechanism. Although this study’s data on accuracy, sensitivity, and specificity are interesting, they are secondary to whether patients with wound problems are told to come into the office for further evaluation or, mistakenly, told to stay home with continued remote monitoring. Especially in the setting of potential surgical site infections, overtriage was much more common than undertriage (42% vs 5% without photographs and 36% vs 10% with photographs).1 Although this finding is exactly as it should be—any remote triage tool should be more sensitive than specific—the association between photographs, surgeon confidence, and undertriage remains a concern. These results call to mind the association between visual perception and heuristic decision making described in a classic article on bile duct injury by Way and colleagues.3 Could it be that a mediocre-quality photograph of a mild or early wound complication manipulates our decision-making process by overriding other, nonvisual data?

Randomized clinical trials (RCTs) are rightfully valued as the primary source of research data that drives changes in practice and directs evidence-based care. However, the time and associated costs of initiating a trial and completing patient accrual and follow-up are important limitations. Among 28 phase 3 studies funded by the National Institute of Neurologic Disorders and Stroke of the National Institutes of Health, the total costs were more than $335 million, with a mean of approximately $12 million and a range from approximately $1 million to $64 million.1 By comparison, data from administrative claims, clinical registries, and electronic health records are readily available, cost-effective, and efficient for conducting observational research. These favorable features make observational data powerful tools that, when used properly, could potentially increase the rate at which scientific evidence is incorporated into contemporaneous clinical practice.

Mission Statement: To promote the art and science of surgery by publishing relevant peer-reviewed research to assist the surgeon in optimizing patient care. JAMA Surgery will also serve as a forum for the discussion of issues pertinent to surgery, such as the education and training of the surgical workforce, quality improvement, and the ethics and economics of health care delivery.

To the Editor Canner et al1 reported that the number of gender-affirming surgeries performed in the United States has been increasing since 2000. To conduct this research, the authors identified hospitalizations for gender-affirming surgical procedures by the presence of diagnosis codes for either transsexualism or gender identity disorder within the discharge record. However, in the 2000s, clinicians avoided using these codes because insurance companies commonly implemented blanket exclusion policies prohibiting reimbursement for gender-affirming services. Instead, clinicians would often use a broader category of codes, such as unspecified endocrine disorder or unspecified disorder of genital organs, when caring for transgender individuals to prevent burdensome and invasive disputes between insurers and patients.

In Reply We appreciate the thoughtful letter from Houck and Oldham referring to our article1 and the accompanying editorial by Kelley-Quon et al.2 Their letter succinctly and clearly summarizes the pertinent standards for the care of children as set forth by the American College of Surgeons Children Surgical Verification Quality Improvement Program. We entirely agree with them in pointing out that our findings are likely not generalizable to children younger than 10 years and that the patient-centered approach to pediatric surgical care endorsed by the American College of Surgeons Children Surgical Verification Quality Improvement Program is commendable.

To the Editor We read with interest the article by Akhtar-Danesh et al titled “Factors Associated With Outcome and Costs After Pediatric Laparoscopic Cholecystectomy”1 and the accompanying editorial by Kelley-Quon et al titled “Considering the Ability of General Surgeons to Add Value to Pediatric Surgery.”2 As leaders of the American College of Surgeons Children Surgical Verification Quality Improvement Program (ACS CSV), we wished to point out that the ACS CSV sets forth standards for institutions providing care for children undergoing surgery but does not specifically advocate for regionalization.3 It is up to local institutional judgment to determine the most appropriate health care professionals for certain surgical procedures, including adolescent cholecystectomy. In terms of pediatric-certified surgical, anesthesia, and nursing personnel, the ACS CSV standards specifically apply to children younger than 5 years and patients with higher acuity (ie, American Society of Anesthesiologists score of 3 or greater). Therefore, each institution must determine by means of institutional credentialing and perioperative quality assurance which surgeons are most capable of providing optimal care for otherwise healthy preteens and adolescents undergoing cholecystectomy.

In Reply In his letter, Talan questions the information provided to survey respondents about antibiotic therapy for appendicitis in our study, describes his ongoing trial, and challenges (but misrepresents) our conclusions. Protocols and outcomes for any therapy will vary in different reported literature. We cited representative studies in our report1 that were consistent with the prospective details that we provided to patients, using information similar to that which we or our colleagues would have provided to patients in an informed consent discussion at study initiation in early 2016. However, we also conducted sensitivity analyses that systematically varied such information to investigate how this affected patient choice. Respondents were more likely to choose surgery than antibiotics alone even if therapy was offered as an outpatient or if the short-term failure rate was less than 10%, although increasing numbers of respondents would have chosen antibiotics under such improved circumstances.

To the Editor In the eAppendix of the Supplement, Hanson et al1 detail their survey in which respondents were asked to imagine they had appendicitis, asked to choose among the treatment options, and given descriptions of the options and outcomes. The survey results by Hanson et al1 describing the public’s preferences for appendicitis treatment may have been different had the assumptions provided about nonoperative treatment of appendicitis (NOTA) been more reflective of our current understanding.

The human and economic losses from a lack of safe surgery and anesthesia care are too large to ignore. More than 70% of the world’s population lacks access to surgical, obstetric, and anesthesia care, and 50% risk financial catastrophe from surgery.1 By adopting World Health Assembly Resolution 68.15 in 2015, adequate access to safe and affordable emergency surgery and anesthesia has been prioritized for all people worldwide by 2030 as a part of universal health coverage.2 Surgery is a complex intervention, requiring a functioning health system, which in turn requires strategic planning. However, most national health plans have no significant mention of surgical care.3 Development of a national strategy to improve surgical care by simultaneously strengthening appropriate infrastructure, a well-trained and well-distributed workforce, efficient service delivery, integrated information management, quality assurance, and adequate financing and governance in low- and middle-income countries is an innovative approach to improve surgical care. Driven by the national government and supporting a wider health strategic plan, a national surgical, obstetric, and anesthesia plan (NSOAP) identifies the current gaps in health care, prioritizes solutions, and provides an implementation framework (specific time-bound, annually prioritized, costed activities to reach each goal), a monitoring and evaluation plan, and projected cost. The NSOAP establishes a unified vision for strengthening of surgical systems and the coordination of efforts required to achieve this.

The Vascular Quality Initiative (VQI) was developed by the Society for Vascular Surgery in 2011 to improve the safety and effectiveness of 12 common vascular procedures (Box). The VQI operates within the structure of a patient safety organization, which protects the quality improvement activities as patient safety work product and thus provides a degree of privilege and confidentiality for the data. Because the VQI is a member of the Society for Vascular Surgery patient safety organization, comparisons with regional and national institutions can be performed.

The Society of Thoracic Surgeons (STS) National Database is a voluntary clinical registry created to facilitate a national quality improvement and safety initiative for cardiac surgery. This progressive initiative led to one of the earliest attempts to provide surgeons with nationally benchmarked, risk-adjusted outcomes. The database (Box) is now also used to facilitate the public reporting of outcomes and clinical research. It consists of 3 components, each focusing on a separate type of cardiothoracic surgery: adult cardiac surgery (established 1989), congenital heart surgery (1994), and general thoracic surgery (2002). Since 1999, the STS has contracted the Duke Clinical Research Institute to warehouse the data, conduct statistical analyses, and provide participants with performance reports.

Surgical residency training represents a demanding period in a surgeon’s career, with continuous exposure to new and potentially highly stressful situations. While there has been increased recognition of the problem of burnout among surgical residents,1,2 few programs have been designed to improve surgical resident well-being. In 2017, the Accreditation Council for Graduate Medical Education began mandating that training programs address physician well-being.3

Optimal care for hepatitis virus–related hepatocellular carcinoma (HCC) would include eradication of tumor and elimination of hepatitis B virus (HBV) or hepatitis C virus (HCV) infection. Accomplishing these goals could prevent deaths from cancer or cirrhosis and reduce the likelihood of viral transmission. Tremendous progress has recently been achieved for tumor and antiviral therapies. Long-term survival from cancer was previously a rarity. Now, partial hepatectomy, liver transplant, or tumor ablation provide 5-year survival rates of 45% to 80%.1 Direct-acting antivirals (DAA) can now prevent cirrhosis in patients with HBV and can produce cures in patients with HCV2 for most patients and with little morbidity. Data are also accumulating that successful antiviral treatment reduces recurrence of cancer. In this issue of JAMA Surgery, Li et al3 examined a cohort of 2552 patients with resection of HCC and demonstrated that preresection (>90 days) effective treatment for HBV is associated with a lower tumor vascular invasion and decreased recurrence.

The opioid crisis is in the national headlines almost daily. Many US states have enacted prescribing restrictions and stipulations to begin addressing the problem. While it is unclear how much of the excess supply of opioids in circulation stems from perioperative prescribing, significant variation in prescribing practices is clear.1,2 We would argue that if practicing surgeons reflected on their own opioid prescribing practices, they would likely identify areas to improve. However, they would also realize the limited resources to appropriately set patient expectations for postprocedure pain and the paucity of evidence available to support approaches to calculating the dose and duration of opioids needed after common surgical procedures or the use of nonopioid analgesic regimens. In this issue of JAMA Surgery, Wetzel et al3 present a systematic review of interventions for postsurgical opioid prescribing, with a focus on system-level interventions, such as practice guidelines and electronic health record modifications. The authors conclude the same thing that many of us have come to realize in our daily practice: that there is evidence that these approaches are effective, but the literature in this area is very limited.

In this issue of JAMA Surgery, Jung and colleagues1 examine the safety and efficacy of venous thromboembolism (VTE) prophylaxis in Korean patients undergoing gastrectomy for cancer. Their randomized clinical trial found decreased postoperative VTE with the use of low-molecular-weight heparin in addition to mechanical prophylaxis, compared with the use of mechanical prophylaxis alone. However, the authors claim that, because the VTE rate was low and the rate of bleeding was increased, VTE prophylaxis (low-molecular-weight heparin plus intermittent pneumatic compression) still may not be the right choice for all patients undergoing gastrectomy. Although we were pleased to see this focus on VTE, which until recently was understudied in Asian patients,2 we do have some questions about this trial and its conclusions.

Opioid use increased in the United States from the early 1990s until very recently, when opioid prescribing appears to have peaked and declined slightly.1 Many institutions are working hard to put the opioid genie back in the bottle, so to speak, and the perioperative period offers a unique opportunity. The focus is on opioid stewardship, during which opioids are carefully used as part of multimodal pain care while improper and excessive opioid prescribing is avoided. This effort includes identification of patients who are at increased risk for harm associated with the use of opioids, so that care to these patients can be modified to optimize outcomes.

Several important questions are raised by Jung and colleagues1 in their article in this issue of JAMA Surgery. The first question is whether retrospective video review can be used to identify technical risk factors associated with the construction of a gastrojejunostomy that might contribute to the development of delayed gastric emptying after pancreatoduodenectomy. Despite the challenges of standardization of technique and the limitations of retrospective analysis, the authors have identified the following 3 technical risk factors for delayed gastric emptying: a gastrojejunostomy flow angle of greater than 30°, a shorter gastrotomy, and a sutured anastomosis.

In their study in this issue of JAMA Surgery, Katz et al1 used a robust population-based data set to evaluate surgeon variation in genetic counseling and testing referrals for patients with breast cancer (BC). They demonstrated that a patient with breast cancer was more likely to undergo genetic evaluation if she saw a surgeon who made frequent genetic counseling and testing referrals. On the surface, Katz et al might seem to be stating the obvious, but more thoughtful consideration of their results triggers the controversial discussion of population-based BRCA genetic testing for all women.

In this issue of JAMA Surgery, 2 studies based on a prospective cohort, the Multicenter Reconstruction Outcomes Consortium, examine the outcomes of breast reconstruction across 11 centers.1,2 The first study examined complication rates of postmastectomy breast reconstruction at 2 years after surgery.1 Patients who underwent autologous reconstruction had greater odds of developing complications and experiencing reoperative complications compared with patients who underwent prosthetic reconstruction, but had a lower chance of infection and failure. Overall failure rates were 7.1% with implant-based techniques and 1.2% for deep inferior epigastric artery perforator flaps. A startling finding was the rate of reoperative complications, which ranged from 15.5% for expander implant reconstruction to 29.2% for the deep inferior epigastric artery perforator flap procedure. These rates are similar to those published by Alderman et al3 in the 2-year follow-up of the Michigan Breast Reconstruction Outcome study conducted more than 15 years ago. Further analysis of the reoperative complications will help us understand and improve these numbers.

Level 1 evidence supports neoadjuvant chemotherapy followed by a radical cystectomy (RC) for treating muscle-invasive bladder cancer (MIBC).1 Given its substantial perioperative morbidity, bladder preservation therapy (BPT) is an alternative treatment option for individuals who wish to avoid or are not able to undergo RC.2 Given the absence of prospective randomized clinical trials, well-designed observational cohort studies currently offer the best comparative effectiveness evidence to evaluate these treatment options.

We thought we had it all figured out. After curative resection of colon and rectal cancer, all clinicians know what to do. The National Comprehensive Cancer Network guidelines1 have been very clear and specific. For stage I, clinicians followup with colonoscopy, and for stages II and III, a combination of physical examination, carcinoembryonic antigen, colonoscopy, and computed tomographic scan of the chest abdomen and pelvis at very specific intervals for a total of 5 years. What can go wrong with such a detailed plan?